PROJECT ABSTRACT Unintended adolescent pregnancy rates remain unacceptably high in the United States, and result in poor health outcomes for the young mothers and their babies, as well as significant social and financial costs to communities and society as a whole. While many factors contribute to the high rate of unintended pregnancies in this age group, an important issue that is potentially amenable to intervention is non-use of contraception. Therefore, research focused on increasing initiation of contraception among adolescents, particularly those at high risk of pregnancy, is crucial. One approach that has been understudied is reaching these adolescents in non-traditional sites of clinical care ? care settings that do not currently routinely provide contraception services. The Emergency Department (ED) is a setting that is well-positioned to provide these services, as almost 19 million adolescents seek care in EDs each year, and many adolescents are amenable to receiving reproductive health care services in this setting. For the highest-risk patients, the ED is often their only or primary contact with the health care system, and so in this setting we have a vital window of opportunity to improve contraception access for adolescents who are unlikely to be reached through other clinical settings. We seek to capitalize on our prior work and our ED programs focused on sexual health education in order to better understand the decision-making around contraception initiation of adolescents at high risk for pregnancy. Our long-term goal is to reduce unintended pregnancy by improving access to contraception among adolescents seeking care in the ED setting. By elucidating factors that affect decision-making as well as barriers and facilitators to conception initiation in the ED setting, we will gain a critical understanding that will lead to developing patient-centered approaches for increasing contraception initiation among these patients. To do this, we will conduct a multi-site, mixed methodology study to assess attitudes, barriers and facilitators to initiating contraception in the ED among this high-risk group of patients. We will adapt contraceptive counseling approaches used in outpatient clinical settings to deliver counseling during the ED visit, and our methods will allow us to explore factors associated with initiation of contraception during and after the ED visit as well as issues affecting follow-up after ED care. Ultimately, we will develop a toolkit supporting contraceptive counseling and delivery in the ED, and design processes to support increased use of contraception among adolescents.